Welcome to the webinar for Presumptive ... - Missouri · Missouri Department of Social Services ......

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Debbi Fletcher

Income Maintenance Program and Policy

Program Development Specialist

Welcome to the webinar for

Presumptive Eligibility for Children

and Pregnant Women

Provider Training

Revised 4/1/2017 PC, TEMP, SMHB-

PE

QUESTIONS?

Revised 4/1/2017 PC, TEMP, SMHB-PE

If you have questions during the webinar, please

feel free to unmute your phone at any time and ask

your question. However, please also send them in

an email to [email protected].

They will be answered and posted on the

Department of Social Services website.

mailto:[email protected]

Missouri Department of Social Services

Presumptive Eligibility for Children

and Pregnant Women

Training for Qualified Entities


Contents

In this training, the following will be covered:

Overview of the Presumptive Eligibility (PE) Program

How Entities can participate in PE

Who is eligible to enroll in MO HealthNet through PE?

What are the benefits?

Terms and Definitions

Forms

Determining Eligibility

Household Composition

Income Determination

Submitting PE applications After the Determination is Completed

Emergency MO HealthNet Care for Ineligible Aliens (EMCIA)

Performance Standards


Presumptive Eligibility

Overview


Presumptive Eligibility (PE) Overview

Presumptive Eligibility allows individuals who meet certain requirements to receive MO HealthNet benefits for a period of time.

PE has been available for pregnant women (TEMP) since 1990 .

PE has been available for breast and cervical cancer treatment since 2001

PE has been available for children since 2003

Show-Me Healthy Babies - PE (SMHB-PE) became an official Missouri program January 01, 2016 and is now available

The Affordable Care Act (ACA) expanded PE to include Parents / Caretaker Relatives and Former Foster Care Youth and is now available.


PE Overview

Following signing a Memorandum of Agreement (MOA) and completion of training, qualified entities may:

Determine PE eligibility for certain individuals who are likely to be eligible for regular MO HealthNet; and

Assist PE applicants to apply for regular MO HealthNet at mydss.mo.gov, by telephone, or by completing the Missouri Single Streamlined Application (IM-1SSL).

What is the fastest way to apply for regular

MO HealthNet?

On-line at mydss.mo.gov; or

By telephone at (855) 373-9994.


PE Overview

Presumptive Eligibility is temporary but allows

immediate access to coverage for eligible

individuals.

PE is not about short-term coverage; it provides an

opportunity to get individuals connected to longer-

term coverage options.

Ensures providers will be reimbursed for services

provided.


How Entities Can Participate

in PE


How Entities Can Participate in PE

Participation in PE is optional, but all states are required to provide a way for entities to become qualified to conduct PE determinations

To become qualified, an entity must:

Participate in the MO HealthNet program;

Notify FSD of the desire to participate in PE: • Email the Family Support Division at

[email protected]; or

• write to PO BOX 2320 Jefferson City, MO 65102;

Have a signed Memorandum of Agreement and agree to make PE determinations consistent with policies and procedures; and

Complete training.




Once an entity has been qualified:

A properly trained and certified employee can make PE determinations

Including employees in hospital-owned physician practices or clinics, and those in off-site locations

NOTE: Participating entities may not delegate PE determinations to non-entity staff

• Third party vendors or contractors may not make PE determinations

Participating entities must meet performance standards set by the state and maintain adequate status as a qualified PE Provider

Performance Standards will be discussed later in this training.



The Family Support Division (FSD) is offering

this provider training to ensure providers are

trained on the requirements associated with

issuing PE to Missouri participants.

If future training is necessary, send an email

to: [email protected]



Who is Eligible to Enroll in

MO HealthNet through PE?


Who is Eligible to Enroll in MO HealthNet

through PE?

Pregnant Women (Temporary MO HealthNet During

Pregnancy or TEMP)

Children’s Health Insurance Program (CHIP) for

Unborn Children (Show-Me Healthy Babies

Presumptive Eligibility or SMHB-PE)

Infants and Children under age 19 (Presumptive

Eligibility for Children or PC)

Parents/Caretakers of children under age 19

(PE for Parents/ Caretaker Relatives or MHF-PE)

Former Missouri Foster Care Youth through age 26

(PE for Former Foster Youth)

Breast and Cervical Cancer Treatment (BCCT-PE)


Missouri Presumptive Eligibility Programs


This training will only address PE for Children and Pregnant Women

PE for Children

Eligibility Requirements

Individual applicant must:

Be an infant or child under age 19;

Not be receiving MO HealthNet under any

other full coverage category;

Not have received PE in the past 12 months;

Be a US Citizen;

Be a resident of Missouri; and


PE for Children



Have income at or below the applicable income

guideline for household size:

Children under age 1: household income must be

at or below 201% of FPL (196% of FPL plus 5%

income disregard)

Children ages 1 thru 18: household income must

be at or below 155% of FPL (150% of FPL plus 5%

income disregard)


PE for Pregnant Women



Be pregnant;

Not be receiving MO HealthNet under any

other category (excluding UWHS, EWHS, or

GTBH);

Not have received PE during the current

pregnancy;

Be a resident of Missouri; and





Have income at or below the applicable income guideline for

household size.

Household income must be at or below:

201% of FPL (196% of FPL plus 5% income disregard) for

TEMP

or

Above 201% and at or below 305% of FPL (300% of FPL plus

5% income disregard) for SMHB-PE

What are the Benefits?


PE for Children

Benefits

Children determined eligible under PE receive the

same coverage as those provided under MO

HealthNet for Kids.



Benefits

Pregnant women determined eligible under PE receive only

pre-natal ambulatory services (pre-natal medical care provided

on an outpatient basis).

NOTE: Newborn coverage is only available if the mother or unborn

child are covered by regular MO HealthNet when the child is born.

Children born to a PE only mother are not eligible for Newborn coverage;

unless the mother is found eligible for retroactive regular MO HealthNet

coverage.


PE for Children and Pregnant Women

Benefits

Benefits are received through fee-for-service.

There are no appeal rights for PE determinations.



Benefits

Coverage, under PE, begins the day the QE makes the PE determination.

PE coverage ends on the earliest of either:

The date the eligibility determination for regular MO HealthNet is made by FSD

The last day of the following month in which the QE made the PE determination (if a regular MO HealthNet application is not filed by the individual).

Example: PE determined 2/8/20xx. Eligibility period 2/8/20xx – 3/31/20xx. FSD determines eligibility for regular MO HealthNet coverage on 2/19/20xx. PE ends the date of the approval or denial for MO HealthNet coverage 2/19/20xx.

Exception: When denied for full coverage under MO HealthNet for Pregnant Women (MPW) only, TEMP eligibility continues for the entire PE period.

NOTE: When an application for regular MO HealthNet benefits is received while the PE coverage is active, the PE benefits will remain open until an eligibility determination is made.




TERM DEFINITION

ACA Affordable Care Act - The Patient Protection and Affordable Care Act

(PPACA), commonly called the Affordable Care Act (ACA), a United

States federal statute, was signed into law on March 23, 2010.

FSD Family Support Division – division of the Department of Social Services

IM Income Maintenance – unit of FSD which determines eligibility for all

MO HealthNet programs

MHD MO HealthNet Division – division of the Department of Social Services

that oversees and implements healthcare services for the MO HealthNet

programs

QE Qualified Entity- an organization that is determined by Missouri to be

capable of making presumptive eligibility determinations. Qualified

entities include, but are not limited to, FQHCs, Hospitals, and County

Health Departments.

FPL Federal Poverty Level



TEMP Temporary MO HealthNet During Pregnancy- provides immediate,

temporary ambulatory healthcare for pregnant women meeting eligibility

guidelines. Up to 201% FPL

SMHB-PE Show-Me Healthy Babies Presumptive Eligibility -provides immediate,

temporary ambulatory healthcare for pregnant women meeting eligibility

guidelines. Up to 305% FPL

PC Presumptive Eligibility for Children - provides immediate, temporary

healthcare coverage to eligible children under the age of 19.

MHF-PE Presumptive Eligibility for Parent/Caretaker Relative - provides immediate,

temporary healthcare coverage to eligible parents and caretaker relatives.

MAGI Modified Adjusted Gross Income - a methodology for determining MO

HealthNet eligibility based on federal income tax filing rules for income

and family size.

Forms Used for Presumptive

Eligibility Determinations


Forms Used for Presumptive Eligibility

Determinations


Application for Presumptive Eligibility

PE-1SSL

../../Implementation/Forms, resources/PE-1SSL Application.docx




Determinations


QE Presumptive Eligibility

Determination Worksheet

PE-2 Worksheet

PE-2 Worksheet final 3-4-16 with cit question.docx



../../Implementation/Forms, resources/PE-2 Worksheet v2.dotx




Determinations


MO HealthNet Presumptive

Eligibility Authorization

PE-3




../../Implementation/Forms, resources/PE-3 PE Auth.docx





Determinations – Pregnant Women Only


MO HealthNet TEMP / SMHB-PE

Authorization

PE-3 TEMP




../../Implementation/Forms, resources/PE-3 TEMP SMHB.docx





Determinations


Appendix A




../../Implementation/Forms, resources/Appendix A- PE Income Standards.docx


Determining Presumptive

Eligibility


Determining Presumptive Eligibility

If you have access to eMOMED, check to see if the

applicant:

is already receiving MO HealthNet coverage; or

has received PE within the last 12 months or if pregnant,

during the current pregnancy;

IF UNABLE TO DETERMINE -

Call the Family Support Division (FSD) at (573) 751-9023

and an Eligibility Specialist (ES) will assist you. The ES

can also find or assign a DCN.

Or send an email to [email protected] with

your request for information




If the individual is not already receiving MO HealthNet and has not received PE in the last 12 months or during the current pregnancy, begin PE determination process by completing and/or assist in completing the Application for Presumptive Eligibility (PE-1SSL)

If the individual is already receiving MO HealthNet or has received PE in the last 12 months or, if pregnant, within the current pregnancy, check the appropriate box on the PE-2 Worksheet, Questions A and B. This person is not eligible for PE.

Mark the ineligibility on the back of the PE-2 Worksheet

and give the applicant a copy of the form.



All PE is based on information as declared by

applicant (self-attestation).

Physical verifications cannot be required,

including proof of pregnancy or income.



We discussed the eligibility requirements

an applicant/household must meet for PE.

Eligibility requirements included the

household’s income being at or below an

income guideline. Income guidelines are

determined based on the size of the

household

Let’s look at how the household size is

determined



Modified Adjusted Gross Income (MAGI)

Method of determining income used for

eligibility

Missouri uses current monthly income

MAGI Households are based upon federal tax

filing rules unless an exception is met

5% income disregard of the applicable income

guideline, refer to Appendix A.



Identifying a PE Household

When determining household size, use the

relationship of the applicant to all other

members of the household.

Household size is determined using:

information from the applicant’s declarations on the

PE-1SSL; and

Calculation for Household Size on the front of the

PE-2 Worksheet.


Tax Filer


MAGI Household – Tax Filing Statuses

Tax

Dependent

Non-Filer

Child

An individual who expects or plans to file a tax

return for the taxable year in which coverage is

being requested.

An individual who expects to be claimed as a tax

dependent by another taxpayer for the taxable

year in which coverage is being requested.

An individual who does not expect nor plans to file

a tax return and does not expect to be claimed as

a tax dependent for the taxable year in which

coverage is being requested.

Individuals under the age of 19




Special Circumstances:

In some circumstances, if there is a step-parent in the home, the step-parent is included in the PE household.

EXAMPLE 1: Sherry, age 10, live with her mother and step-father. Her mother is applying for PE for Children for Sherry. Sherry is a dependent on her mother and step-father’s federal income taxes. Sherry’s household consists of Sherry, her mother, her step-father, and any other dependents they claim on taxes.

EXAMPLE 2: Cassie, age 19 and pregnant, lives with her father and step-mother. Cassie does not file taxes, but her father and step-mother claim her as a dependent on their taxes. Because Cassie is a dependent on her father’s taxes, her father and step-mother must be counted in her household, along with Cassie and her unborn child.




Special Circumstances (cont’d):

The number of unborn children are included in a

pregnant woman’s household size.

If the father of the unborn child lives in the home, but is

not the spouse to and not filing taxes with the pregnant

woman, he is not included in the TEMP/SMHB-PE

household.



Let’s look at some examples



PE Household Size –Ashley

Household:

Lela Taylor – mother of Ashley and Eric

David – spouse to Lela, father to Eric

Ashley – Lela’s daughter, age 12

Eric – Lela and David’s son, age 7

Lela is applying for PE for Ashley.

Lela and David file federal taxes jointly and claim

Ashley and Eric as tax dependents.



PE Household Size – Ashley



PE Household Size – Bernie

Household:

Betty Schuman – mother to Bernie

Robert – spouse to Betty, father to Bernie

Bernie – Betty and Robert’s son, age 2

Betty is applying for PE for Bernie.

Betty and Robert file federal taxes together and claim

Bernie as a tax dependent.



PE Household Size – Bernie



PE Household Size –Emma

Household:

Georgia Jefferson – mother of Emma

Emma – Georgia’s daughter, age 8

Georgia is applying for PE for Emma.

Georgia files taxes and claims Emma as a

dependent.



PE Household Size –Emma



PE Household Size – Nadia

Household:

Nadia – applicant, age 17, pregnant, expecting one

child

Megan – Nadia’s mother, age 41

Lester – Nadia’s father, age 42

Tonya – Nadia’s sister, age 14

Megan is applying for PE for Nadia.

Lester and Megan, Nadia’s parents, claim both Nadia

and Tonya as federal tax dependents.



PE Household Size – Nadia


For each question below, enter the number of persons.

a. Applicant 1

b. If applicant is pregnant, how many children are expected this pregnancy 1

c. Enter 1 if Spouse lives with applicant 0

d. If applicant files taxes, enter number of tax dependents claimed

on federal tax return. If applicant does not file taxes, enter

number of children under age 19 living in their household. 0

NOTE: DO NOT include people listed in lines a or c.

e. If applicant claimed by parent(s) on their federal tax return, count

the parent(s) including step-parent(s) and other siblings who

are claimed by the parents and enter that number here. If not

filing taxes and you are under age 19, count your parent(s) including

step parent(s) and other siblings under age 19. 3

NOTE: DO NOT include people listed in lines a, c or d.

f. Total Household size (add lines a, b, c, d, and e then enter this amount

on page one under household size): 5


PE Household Size – Donna

Household:

Donna – applicant, age 31, pregnant, expecting

one child

James – spouse

Donna is applying for PE for herself.

Donna and James are filing federal taxes jointly for

this year.



PE Household Size – Donna



a. Applicant 1





number of children under people listed in lines a or c.










PE Household Size – Latonya

Household:

Latonya – applicant, age 29, pregnant, expecting

one child

Treyvon – boyfriend, age 30, and father of unborn

child and Brian

Brian – son of Latonya and Treyvon, age 4,

Latonya is applying for PE for herself.

Latonya does not file taxes with Treyvon.

She is claiming Brian as a federal tax dependent.



PE Household Size – Latonya



a. Applicant 1





number of children under people listed in lines a or c. 1










Calculating MAGI Income

Now that we determined the PE

household size, let’s look at how to

calculate household income.

General rule is the same as tax definition:

• If income is taxable it is counted

• If income is non taxable it is not counted

Also, if an individual is part of the PE

household, his/her income must be

considered.




There are 2 exceptions on whether or not to count income.

Exception 1:

If an individual is under age 19, are they expected to be required to file taxes?

EXAMPLE A: Jack’s father has applied for MO HealthNet coverage for Jack and his siblings. Jack is age 17 and lives in his father’s household. Jack’s father claims Jack as a dependent on his federal taxes. Jack works and is required to file income taxes (his annual income exceeds the threshold below). Jack’s income must be included in the father’s household.

EXAMPLE B: Ben’s father has applied for MO HealthNet coverage for Ben and his siblings. Ben is age 17 and lives in his father’s household. Ben’s father claims Ben as a dependent on his federal taxes. Ben works and is not required to file income taxes (his annual income is less than the threshold below). Ben’s income is not included in the father’s household.

Note: Federal tax laws require persons who earn at least the threshold amount or greater,

must file taxes. These threshold amounts change annually. The current tax thresholds are:

Individuals earning more than $10,350 per year;

Couples filing jointly earning at least $20,700 per year;

Individuals filing as a head of household earning at least $13,350 per year.




Exception 2:

If an individual is expected to be claimed as a tax dependent of another

household member his/her income counts.

EXAMPLE: Janet is age 19 and claimed as a dependent on her mother’s

federal income taxes. Janet’s mother is applying for MO HealthNet for

Janet’s younger siblings. Janet has income. Because Janet is her mother’s

dependent her income must be included in the mother’s household.




Countable income includes: Taxable Wages/Salary (before taxes are taken out)

Pretax contributions to dependent care accounts, health insurance premiums, flexible spending accounts, retirement accounts and commuter expenses are NOT included as income

Self-Employment

Profit once expenses are paid

Social Security Benefits

Unemployment Benefits

Alimony Received

Most Retirement Benefits

Interest – including tax-exempt interest

Net Capital Gains

Most investment income

Rental or royalty income

Other taxable income

Lump sum is only counted in the month received

Income of child under 19 who is required to file taxes, as his/her income equals or exceed the federal tax filing threshold




Non-Countable income includes:

Temporary Assistance and other government cash assistance

Supplemental Security Income (SSI)

Child Support Received

Veteran’s Benefits

Workers Compensation Payments

Proceeds from life insurance, accident insurance, or health

insurance

Federal tax credits

Scholarships, awards, or fellowship grants used for education, but

not living expenses

American Indian/Alaskan Native income derived from distribution,

payments, ownership interests, and real property usage rights

Income of a child under age 19 who is not required to file taxes, as

his/her income is less than the federal tax filing threshold




MAGI is determined using Federal tax rules. These

rules include the use of tax adjustments or

deductions.

Most common deductions are:

Certain self-employment business expenses

Alimony paid

Health savings accounts

Student loan interest paid

PE Income deductions are based on the

participant’s attested amount.





Lines 23-35 show all the allowable deductions on the current IRS

Form 1040. They may be used to calculate MAGI income if the

applicant states they file income taxes and claim deductions.



Basic steps to determine MAGI income:

Determine household’s countable

monthly income

- Household’s monthly tax

deductions

= Modified Adjusted Gross

Income Compare to income maximum for

appropriate MO HealthNet program



Examples

Let’s look at completing the PE-2 Worksheet,

including how MAGI is calculated. We will work

with the same households we looked at earlier in

the training:

Lela

Betty

Georgia

Nadia

Donna

LaTonya



PE for Children - Ashley

Household:

Lela – mother, age 39

David – father, age 41

Ashley – Lela’s daughter, age 12

Eric – Lela and David’s son, age 7

We determined Ashley has a 4 person household.

Ashley:

• Is not receiving any MO HealthNet benefits;

• has not received PE in the past 12 months.

• is a resident of Missouri;

• is a U. S. citizen; and

• is not filing federal taxes.

Household income:

Lela earns $1,500.00 monthly

David earns $500.00 weekly

Ashley receives child support - $150.00 monthly



PE for Children - Ashley



PE for Children - Bernie

Household:

Betty Schuman – mother of Bernie

Robert Schuman – father of Bernie

Bernie – Betty and Robert’s son, age 2

Betty is applying for PE for Bernie. We already determined that Bernie has a household size of 3.

Bernie:


• has not received PE in the past 12 months.




Betty and Robert file federal taxes together and claim Bernie as a tax dependent.

Household income:

Betty earns $9.00 per hour, works 15 hours per week, and is paid weekly

Robert earns $15.00 per hour, works 30 hours per week, and is paid biweekly





MO HealthNet Presumptive Eligibility

Authorization PE-3

../Children/Scenarios/Betty/PE-3 PE Auth-Betty.docx





PE for Children - Emma

Household:

Georgia – Emma’s mother

Emma – applicant, age 8

Georgia is applying for PE for Emma. We have already determined she is a

household of 2.

Emma:

• is not receiving any other MO HealthNet benefits;

• has not received PE within the last 12 months;




Georgia files taxes and claims Emma as a dependent.

Household income:

Georgia earns $1,000.00 twice a month





MO HealthNet Presumptive Eligibility

Authorization PE-3

../Children/Scenarios/Georgia/PE-3 PE Auth-Georgia.docx





PE for Pregnant Women - Nadia

Household:

Nadia – age 17, pregnant with one child, full time student, and works part time.

Megan – Nadia’s mother, age 41

Lester – Nadia’s father, age 42

Tonya – Nadia’s sister, age 14

We determined Nadia has a 5 person PE household (this includes the unborn child)

Nadia:


• has not received PE during the current pregnancy;

• is a resident of Missouri; and


Monthly household income:

Nadia earns $281 monthly

Megan earns $1800 monthly

Lester earns $2600 monthly





MO HealthNet TEMP/SMHB-PE

Authorization (PE-3 TEMP)

../Pregnant Women/Scenarios/Nadia Walker/PE-3 TEMP-Nadia.docx







PE for Pregnant Women - Donna

Household:

Donna – applicant, pregnant with one child

James – Donna’s spouse

We determined Donna has a 3 person PE household (this includes the unborn child)

Donna:




• is filing federal taxes jointly with James.

Monthly household income:

Donna earns $850 biweekly

James earns $2500 monthly






Authorization (PE-3TEMP)

../Pregnant Women/Scenarios/Donna Worth/PE-3 TEMP-Donna.docx








PE for Pregnant Women - LaTonya

Household:

LaTonya – age 29, pregnant with one child

Treyvon – LaTonya’s boyfriend, age 30, and father of her unborn child and Brian

Brian – LaTonya and Treyvon’s son, age 4

We determined LaTonya has a 3 person PE household (this includes the unborn child

and Brian)

LaTonya:




• is filing federal taxes by herself and claiming Brian as a dependent.

Household income:

LaTonya is self employed, earns $1500 monthly, and claims $285 in deductions

Treyvon earns $4000 monthly



PE for Pregnant Women - LaTonya



Examples - LaTonya



Authorization (PE-3TEMP)

../Pregnant Women/Scenarios/Latonya Harden/PE-3 TEMP-LaTonya.docx







What’s Next?

We have:

Reviewed the PE-1SSL, PE-2 Worksheet, PE-3 MO HealthNet Presumptive Eligibility Authorization, and PE-3TEMP MO HealthNet TEMP / SMHB-PE Authorization

Completed the PE-2 Worksheet which included:

household size;

household income; and

determination of eligibility.

Completed the approval notice PE-3 or PE-3TEMP

It’s time for you complete the PE process.


Processing a PE Application after

the Determination is Completed




If individual meets all requirements:

Provide the individual with a completed authorization form (PE-3 or PE-3TEMP).

The PE-3 or PE-3 TEMP is used to obtain covered medical services for the identified individual(s) from an enrolled MO HealthNet fee-for-service provider.

Notify the individual/family of the PE coverage period

If you haven’t already done so, assist the individual in completing the on-line, telephone, or paper application (IM-1SSL) and advise individual that if a paper application is completed it will be sent to the FSD for a formal determination of on-going eligibility for MO HealthNet coverage.

If eligible for on-going coverage, a white, plastic “MO HealthNet” card is sent to individual(s).

Submit appropriate PE forms and supporting documents to FSD




DO NOT send the Presumptive Eligibility Application (PE-1SSL) to FSD. This is kept on file in your facility.

Send the following forms to the FSD the same or next day so it is received by FSD within five (5) working days of the determination:

Family MO HealthNet application (IM-1SSL) if completed.

NOTE: If an application was submitted, indicate how it was submitted at the top of the PE-2 Worksheet

Copy of Presumptive Eligibility Determination (signed PE-2 Worksheet)

Copy of the MO HealthNet Presumptive Eligibility Authorization (PE-3) or MO HealthNet TEMP/SMHB-PE Authorization (PE-3TEMP)

Any other documentation submitted by the individual

Maintain copies of all forms used in determination process for 5 years Can be saved in a paper or electronic file




If individual does not meet all requirements:

Provide the individual/family with a copy of the signed PE-

2 Worksheet, including the reason the individual(s) is

ineligible for presumptive MO HealthNet.

Assist the individual in completing the on-line, telephone,

or paper (IM-1SSL) application. Advise individual that if a

paper application is completed it will be sent to the FSD

for a formal determination of on-going eligibility for MO

HealthNet coverage.

Submit appropriate PE forms and supporting documents

to FSD





DO NOT send the Presumptive Eligibility Application

(PE-1SSL) to FSD. This is kept on file in your facility.

Send the following forms to the FSD the same or next day so it is

received by FSD within five (5) working days of the determination:

Family MO HealthNet application (IM-1SSL) if completed.

NOTE: If an application was submitted, indicate how it was

submitted at the top of the PE-2 Worksheet

Copy of Presumptive Eligibility Determination (signed PE-2

Worksheet)

Any other documentation submitted by the individual

Maintain copies of all forms used in determination process for 5

years

Can be saved in a paper or electronic file



PE Documents may be submitted to

the FSD with PE or Presumptive

Eligibility in the “subject” or ”attention

to” lines by:

email at [email protected]; or

fax to (573) 751-0282.



Emergency MO HealthNet Care

for Ineligible Aliens (EMCIA)


What is EMCIA?


Emergency MO HealthNet Care for Ineligible Aliens is a

program under the Social Security Act that:

provides coverage for emergency medical care of aliens who meet

all eligibility requirements for a federally funded MO HealthNet

program except citizenship/alien status.

provides coverage for ineligible aliens only for the dates of the

emergency medical care.

What is EMCIA?


An emergency medical condition is defined as follows:

The medical condition must be one that manifests itself by acute

symptoms of sufficient severity (including severe pain) such that the

absence of immediate medical attention could reasonably be

expected to result in:

Placing the patient's health in serious jeopardy;

Serious impairments to bodily functions; or

Serious dysfunction of any bodily organ or part.

All labor and delivery is considered an emergency medical condition.

What is EMCIA?


One of the requirements of all MO HealthNet

programs is that the applicant must be a resident

of Missouri.

Individuals in the United States as tourists or

visitors are not eligible for this program as they

would not meet the residence requirements.

When to Use EMCIA


EMCIA coverage should be considered for ineligible

aliens when they have an emergency situation and:

the individual is not eligible for PE; or

the individual is not eligible for regular MO HealthNet

coverage.

NOTE: Women who apply for Show-Me Healthy Babies on or after

the day their child is born are not eligible for SMHB coverage. They

will need to apply for EMCIA.

NOTE: A larger number of EMCIA applications could occur with the

change in regulation for PE requiring children and parent/caretaker

relatives to be US citizens

How to Apply for EMCIA


The individual should complete a regular MO HealthNet

application (on-line, phone, or a paper application).

FSD needs to know which person on the application

needs emergency coverage and the dates of the

emergency

Medical records for the specific dates of service and

other required verification may be requested.

How to Apply for EMCIA


Submit EMCIA applications and documentation:

By email: [email protected] (Subject line –

EMCIA); or

By fax: (573) 751-0282 (Attention to - EMCIA)


PE Performance Standards



To remain a PE provider, the following performance

standards must be met:

Check for existing MO HealthNet coverage

prior to completing PE determination.

Expectation: Correct determination on 98% or

more of applications

Check for receipt of PE within past 12 months,

or current pregnancy (TEMP/SMHB)



Determine PE accurately.





Assist applicants in completing and submitting

a full MO HealthNet application

Expectation: 90% of these application should

be received prior to end date of PE period

Full MO HealthNet applications submitted

prior to end of PE period will be used to

determine ongoing MO HealthNet eligibility.

Expectation: 95% of these applications should

be approved for ongoing coverage

NOTE: Ongoing applications rejected because the

applicant did not meet citizenship/qualified alien

criteria or did not provide verification will not be used

in this measurement.



The state has the authority to take

corrective action against Qualified Entities,

including termination from the PE

program, if the QE does not follow state

policies or does not meet established

standards



If performance standards are not met: QE receives notification from the Family Support Division

(FSD)

QE submits a corrective action plan (CAP) for review by FSD

Upon approval of CAP, QE must implement and complete the CAP within a specified time frame

If QE does not submit a CAP accepted by Division or again fails to meet performance standard, QE may be disqualified as a PE qualified entity for the period of 3 years

If QE is disqualified, QE receives notice 30 days prior to disqualification

QE has 10 calendar days to submit a request for reconsideration to the department director Reconsideration is within the discretion of the department director


Contact Information for Providers


Family Support Division (FSD) Program and Policy Unit for Eligibility Questions [email protected]

To find or assign a DCN: (573) 751-9023 or send an email to [email protected]

FSD Information Center: 855-373-4636 (available M-F 7:30 am – 5:30 pm)

Submitting PE determinations and documentation

By email: [email protected] (Subject line – PE or Presumptive Eligibility)

By fax: (573) 751-0282 (Attention to - PE or Presumptive Eligibility)

Submitting EMCIA applications and documentation

email: [email protected] (Subject line – EMCIA)

fax: (573) 751-0282 (Attention to - EMCIA)

Submitting Regular MO HealthNet applications and documentation:

On-line - www.mydss.mo.gov

Telephone – (855) 373-9994

Paper application (IM-1SSL) in-person, by mail, or dropped off at a local office or resource center.

MO HealthNet Division (MHD) Provider Communications: 573-751-2896

MHD Provider Participant page: http://dss.mo.gov/mhd/providers/

(Benefit Matrix and Puzzled by the Terminology? are found on this page under General Information.

Provider Education Unit email: [email protected]





http://www.mydss.mo.gov/

http://dss.mo.gov/mhd/providers/


Questions/Comments

If you have questions, please send them to: [email protected].

They will be answered and posted on the Department of Social Services website:

https://mydss.mo.gov/

Click on “Services” in the banner

Click in the “Health Care” box

Scroll down to “Additional Resources”

Click on “Presumptive Eligibility (PE) Resources for Providers”





https://mydss.mo.gov/pe-resources-for-providers

https://mydss.mo.gov/pe-resources-for-providers

Welcome to the webinar for Presumptive ... - Missouri · Missouri Department of Social Services ......

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